Methods and Devices for Rapid Assessment of Severity of Injury

ABSTRACT

Methods and devices for rapid assessment of the severity of injury not due to a natural disease based upon measurement of neutrophil gelatinase-associated lipocalin (NGAL) are provided.

FIELD OF THE INVENTION

The present invention provides methods and devices for assessing the severity of injury in a subject due to physical or chemical causes, ie not due to natural disease and prognosticating survival of the injured subject by measurement of a biomarker in a bodily fluid of the subject at the site of injury, point of first care or the hospital. In these methods and devices, the biomarker measured is neutrophil gelatinase-associated lipocalin (NGAL). The present invention is thus useful in the field of clinical medicine and surgery, in particular in the fields of traumatology, trauma surgery, emergency medicine, critical care medicine, first aid and rescue work.

BACKGROUND OF THE INVENTION

The current method of assessing the severity of injury is by visual inspection and clinical examination by the first responder at the site of presentation of the injured subject. This is a subjective evaluation conditioned by the level of medical or first-aid training of the responder, which may vary from complete lack of training or experience to a high level of training and experience in emergency medicine and rescue work. However, it is difficult even for trained physicians to make a precise evaluation of the severity of injury of victims of mass-casualty incidents (Ashkenazi et al. Prehospital Disaster Med. 2006 21:20-23).

In everyday cases of injury, the injured subject will be brought at the slightest suspicion of non-triviality to a hospital or trauma center. In mass casualty situations such as accidents, natural disasters and hostile acts such as bomb explosions where a large number of people, typically in excess of 10, are injured, this is not feasible because of lack of immediately available resources. Thus, triage, defined as prioritizing of the injured survivors for treatment or transport to treatment facilities in order to obtain the best overall outcome in terms of survival or the avoidance of permanent disability, is applied. The more accurate the triage, the higher the survival rate and the lower the number of complications leading to prolonged hospitalization or lifelong disability.

Injury severity scoring, as exemplified by the Injury Severity Score (ISS), which is standard practice at many centers for the treatment of trauma, is based on an anatomic examination. It estimates the severity of the most severe injury to each part of the body. The procedure takes time and does not take into account changes in the patient's physiological state including those due to internal bleeding, changes in fluid balance and activation of the blood clotting system. Furthermore, injury severity scoring systems do not take into account the progression of such changes during the time interval from the injury to the moment of scoring.

The present invention remedies defects of injury severity scoring by measuring the concentration in a bodily fluid of a biomarker that reflects the body's response to injury and hence reflects the change in the condition of the patient.

SUMMARY OF THE INVENTION

An aspect of the present invention relates to a method for assessing severity and determining prognosis of an injury due to physical or chemical causes in subject comprising determining a level of neutrophil gelatinase-associated lipocalin (NGAL) in a bodily fluid of the subject. The method of the present invention is preferably performed in the field at the site of injury or at the first point of care or on admission to the hospital.

Another aspect of the present invention relates to portable devices for measuring a level of neutrophil gelatinase-associated lipocalin (NGAL) in a bodily fluid of the subject suffering from an injury due to the said causes which can be used at or near a site of injury or first point of care to assess severity and prognosis of the injury in the subject.

For preferred application of the present invention, methods and devices used to measure NGAL must be performable by persons without laboratory training on small, portable, preferably pocket-sized and battery-powered devices under field conditions, and give results within a few minutes.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows plasma levels of NGAL (mean ±standard error of the mean) in 52 patients with mild trauma (ISS <9), 26 patients with moderate trauma (ISS 9-15) and 32 patients with severe trauma (ISS >15) immediately on hospital admission (time 0) and at 6, 12 and 24 hours thereafter.

DETAILED DESCRIPTION OF THE INVENTION

The present invention relates to methods and devices for determining the severity and prognosis of injury due to physical agents such as impact, crush, blast, burns or irradiation, or any type of exposure to noxious chemical agents, in a subject, preferably a mammal, more preferably a human, by measuring a level of neutrophil gelatinase-associated lipocalin (NGAL) in a bodily fluid including, but not limited to blood, plasma, serum, urine and bronchoalveolar lavage fluid, preferably blood or urine. The injury may be any type of externally caused injury, but not a naturally occurring disease. Measurement of NGAL can be performed using any method or device that is capable of determining NGAL levels in either a quantitative or a qualitative manner. The result of this measurement provides objective information about the pathophysiological responses to the injury. Further, repeated measurements provide information about the progress of the injured subject. This will enable the health care provider or first responder at the scene at which the injured subject is encountered to institute appropriate immediate measures, to prioritize the care of the subject in relation to other injured subjects at the scene of a major accident, disaster or hostile attack, and to inform the hospital or other care facility that is due to receive the injured subject. The objective information regarding the injured subject's status will help the health care providers select and provide appropriate treatment as well. The present invention can be used in any situation in which this assessment of the consequences of injury is wanted, whether or not hospital facilities are available.

NGAL (neutrophil gelatinase-associated lipocalin) is a protein of neutrophils and certain epithelial cells, including epithelial cells of the respiratory tract, the gastrointestinal tract and the genito-urinary tract. We have surprisingly observed in a series of human subjects (see Example 4) that major trauma gives rise to a release of NGAL into the blood. The cellular or tissue origin of this rise is unknown, but it takes place so early that it cannot be attributed to pathologies that have previously been described to release NGAL, such as inflammation and renal ischemic injury. The increase in the concentration of NGAL in the bodily fluids may be the result of increased NGAL release from many organs and tissues, such as muscles, soft tissue in general and bones, and does not necessarily indicate a specific injury to a single organ. Determination of levels of NGAL in bodily fluids such as blood or urine in accordance with the present invention therefore provides an overall indication of the severity of injury and constitutes a prognostic indicator of the outcome. In a preferred embodiment the invention does not relate to an isolated injury of kidneys or to injury of kidneys at all.

Methods of the present invention can also be used to assess the degree of exposure of a subject to whole body radiation after e.g. nuclear detonation. Subjects who are not visibly injured may still be injured by penetrating ionizing irradiation of major epithelial structures, such as the epithelia of the gastrointestinal tract and lungs. The response of these epithelia to radiation injury will be reflected by an increased release of NGAL into the blood. Thus quantification of NGAL in the blood of a subject can be used to assess the severity of whole body exposure to ionizing radiation and can be used to determine whether the subject should be treated with free-radical scavenging agents designed to protect the subject from the effects of radiation exposure. Such drugs are toxic and it is an advantage to restrict their application to subjects that can be shown to have been sufficiently exposed to justify their use.

Methods of the present invention can also be used to assess the consequences of exposure of the subject to chemical agents, such as noxious chemical agents, especially exposure by the inhalation of gases, powders or aerosols. These will provoke release of NGAL from the epithelium of the respiratory tract and may have further effects to release NGAL from other tissues if absorbed into the circulation.

Methods of the present invention can also be applied to injured mammals other than humans, such as production animals like cattle. The quantification of NGAL in blood from an injured animal can provide important information about the cost-effectiveness of treating the animal and aid in decisions on whether the animal should be treated or sacrificed.

An important feature of the present invention is that a sample of bodily fluid in which NGAL is to be measured is taken as soon as possible after a time of 15 minutes is estimated to have elapsed since the injury, and in any case within no more than 12 hours of the injury, such as within 6 hours of the injury, preferably within 2 hours of injury and most preferably within 1 hour after the time of injury.

In accordance therewith and with the use of this invention to assess casualties in the field, the level of NGAL in the sample is preferably measured by a rapid method that can be performed by personnel who are not trained in laboratory techniques and which can be used in the field at the scene of accidents, including multi-casualty accidents, disasters or hostile acts. In this context, the term “rapid” means within 10 minutes, more preferably within 5 minutes and even shorter times, such as 2 minutes. The method and any devices of the present invention thus fall within the category of clinical analyses known as “point-of-care” or “near-patient” testing. The present invention is not limited to any particular test method or format. However, in a preferred embodiment, means for measuring NGAL levels in accordance with the present invention fulfills the requirements of providing the test result within the stated time, uses only equipment that can readily be carried to the site of testing, and can be operated by personnel without specialized training beyond a short introduction.

NGAL in bodily fluids has been quantified previously by immunoblotting (“Western” blotting) and enzyme-linked immunosorbent assay (ELISA). These methods are relatively slow and require non-portable laboratory equipment operated by trained staff. These methods are therefore unsuited to the preferred application of the present invention.

NGAL in a sample can also be measured indirectly, by determining a functional activity of the NGAL, for example by its capacity to bind a natural or synthetic ligand, the concentration of which can also be measured by means of an antibody.

Thus, by the term “level” as used herein it is meant to include concentration of NGAL and/or functional activity of NGAL.

Devices of the present invention measure an individual sample, which is preferably urine or more preferably whole blood taken with a sampling device separate from, or incorporated with the device, and for blood samples coated with an anticoagulant. The sample is applied to an individual test cassette, which contains the antibodies and antibody conjugates in a precisely aliquoted and stabilized form necessary for the analysis of NGAL levels. Such antibodies and antibody conjugates may be bound to a solid phase, or dissolved in a solution containing preservatives and stabilizers, either case permitting a shelf life of at least 6 months at an average ambient temperature of 25 degrees centigrade. The test cassette also contains the support systems that allow the analytical process to proceed automatically once the sample is applied and the cassette inserted into a portable reading instrument carried separately or incorporated within the device itself. The test cassette is small enough to permit at least 10 such cassettes to be carried in a pocket and to fit into a pocket-sized reading instrument, for example the dimensions are smaller, and preferably much smaller, than maximum dimensions of 15 cm long, 5 cm wide and 2 cm deep, the total volume not exceeding 50 cubic centimeters. Each production batch of test cassettes is produced with a consistency such that the coefficient of variation of test results obtained with the same sample applied to different individual cassettes is less than 10%, preferably less than 5%. Said features distinguish the analytical methods and devices to be used in the present invention from the analytical methods previously used to measure NGAL.

The method of the present invention in one embodiment comprises the steps of measuring the concentration of NGAL in a sample of bodily fluid from the individual whose injury is to be assessed, and comparing the measured concentration with a selected cutoff value determined to exceed the concentration values found in healthy, uninjured individuals. The extent to which the measured NGAL concentration exceeds the cutoff level is indicative of the intensity of the pathophysiological response to injury and hence provides an indication of the severity of the injury.

The cutoff level for blood plasma below which the concentration NGAL cannot be indicative of injury severity because such a level can be found in healthy, uninjured individuals is preferably a level of 80 ng/mL or more, such a value between 80 ng/mL and 110 ng/mL, such as 85 ng/mL, or 90 ng/mL, or 95 ng/mL, or 100 ng/mL, or 105 ng/mL.

The cutoff level for urine below which the concentration NGAL cannot be indicative of injury severity because such a level can be found in healthy, uninjured individuals is preferably a level of 10 ng/mL or more, such a value between 10 ng/mL and 30 ng/mL, such as 15 ng/mL, or 20 ng/mL, or 25 ng/mL.

There are various clinical situations in which the rapid analysis of NGAL in accordance with the present invention may be applied.

One exemplary embodiment is in mass-casualty situations such as major accidents, e.g. train crashes, or natural disasters, e.g. earthquakes, or acts of war or terror, e.g. bomb explosions, where there is a need for the triage of a large number of victims. The rescue worker will carry capillary blood sampling devices, and the equipment necessary for field measurement of NGAL. The use of the invention will provide an objective assessment of injury severity which will complement the visual assessment and improve the accuracy of triage, especially in cases of internal injury.

Another exemplary embodiment is at accidents, such as traffic accidents, involving a smaller number of casualties. The invention will enable the first responders to obtain an objective assessment of injury severity which may influence the decision on where to take the injured (i.e. to which level of trauma center) and will improve the information that they can give to the receiving hospital on what to expect.

Another exemplary embodiment is in situations where hospitals and medically trained personnel are far away. This could be in Navy or civilian ships at sea, coastguard or other patrols, or hunters, mountaineers, prospectors or explorers in remote areas. The invention will objective injury assessment to the rescuer who has to take the decision whether or not to get the injured to hospital by helicopter or by making for the nearest harbor.

Another exemplary embodiment is in situations where an injured subject has been transported to a trauma center and the steps necessary to ensure immediate survival have been taken. Determination of the NGAL concentration in a bodily fluid, or the change in concentration from a previous determination, will provide objective information on the subject's status or progression that assist in further clinical decision-making.

Another exemplary embodiment is the assessment of whole body radiation exposure in subjects that have been exposed to penetrating ionizing irradiation without traumatic injury. The estimation of radiation injury to organs such as the gastrointestinal tract and lungs will assist in deciding whether or not to treat with relatively toxic radiation protection drugs.

Another exemplary embodiment is the assessment of an injury due to intoxication, including exposure to noxious chemical agents in the form of gases, powders or aerosols.

Another exemplary embodiment is the assessment of an injured animal to assist in deciding whether or not to treat the animal.

The following non-limiting examples are provided to illustrate how the analysis of NGAL in accordance with the present invention may be performed.

EXAMPLES Example 1 Immunochromatographic or “Lateral Flow” Device

A lateral flow device comprised of a strip of porous nitrocellulose is coated near its distal end with a capture antibody, capable of binding only NGAL, applied as a transverse band. A further transverse band of antibody against antibodies of the species from which the detection antibody is derived is placed distally to the capture antibody band and serves as a control of strip function. The proximal end of the strip contains the detection antibody against NGAL adsorbed or linked to labeled polystyrene particles or particles of dye complex. This is overlaid by a filter that retains red blood cells in the sample. When an aliquot of urine or blood (taken with an anticoagulant-coated capillary dispenser) is applied to the proximal end of the strip, the labeled particles attached to detection antibody travel along the strip by capillary attraction. When reaching the band of capture antibody, only those particles which have bound NGAL in the sample will be retained, giving rise to a detectable band. Particles reaching the control band of antibody against the detection antibody will produce a detectable band whether or not any NGAL has been bound. The intensity of the labeled bands can be read by eye in the case of colored particles or by means of the appropriate detection device for the label used. A positive result is indicated by color development or the accumulation of label in both bands, while a negative result is indicated by color development or other label only in the control band. Failure of color development or other label in the control band indicates inadequate strip function. The sensitivity of the test can be regulated by adjusting the proportion of labeled particles coated with detection antibody. Batches of strips can be pre-calibrated and equipped with a calibration code that can be read by the detection device, so that a quantitative or semi-quantitative result can be read from the device. The device may be a battery-powered handheld device of dimensions that allow it to be carried in an appropriate jacket or leg pocket of a rescue worker's uniform. Many variations of the individual aspects of this lateral flow technology are possible, as known to those skilled in the art.

Example 2 Minicolumn Device

The minicolumn contains a frit made of compressed polyethylene particles allowing the passage of fluid and red cells. The frit is coated with capture antibody against NGAL. The minicolumn is incorporated into a device, which by means of automated liquid handling allows the fixed volume of urine or anticoagulated blood to be applied at a fixed flow rate and volume, followed by detection antibody against NGAL complexed with dye. After the passage of wash solution, the color intensity of the frit is read by light diffusion photometry. The batches of frits are pre-calibrated and the minicolumns equipped with a calibration code that can be read by the device, so that a quantitative result can be displayed by the instrument without the need for prior calibration with standards. This portable instrument can also be made suitable for field use.

Example 3 Turbidimetric Device

The fixed volume of anticoagulated sample is dispensed into a cassette containing a dilution of antibody against NGAL. The reaction of the antibody with the NGAL in the sample produces turbidity proportional to the NGAL concentration, which can be read by a small, portable battery-operated photometer. The intensity of the turbidity signal can be increased by conjugating the NGAL antibodies to polystyrene microspheres. This or similar intensification methods using antibody-coated microparticles will probably be necessary because of the low concentration range at which NGAL has to be measured. Many variations of the individual aspects of this turbidimetric technology are possible, as known to those skilled in the art.

Notwithstanding the above, it is evident that the principle of estimating the extent of injury by the measurement of NGAL in a bodily fluid can also be applied within hospitals, where the measurement can be performed in automated equipment in central laboratories. Performance of the test in hospitals also extends the possible application of the invention to samples of fluids that cannot be obtained outside hospitals, such as bronchoalveolar lavage fluid.

In the following example, plasma NGAL was measured in a series of trauma patients immediately on admission to hospital to obtain the closest simulation of the invention that could be made without the availability of a portable device for measurement of NGAL at the site of accident.

Example 4 Plasma Levels of NGAL in Trauma Patients on Hospital Admission and During the First 24 Hours Thereafter

Blood samples were collected from a series of 110 unselected trauma patients immediately on admission to a level-1 trauma center and at 6, 12 and 24 hours thereafter. The median time from the occurrence of injury to admission was 45 minutes. The plasma samples were subsequently analyzed for their concentration of NGAL by means of a sandwich ELISA technique and the results related to the injury severity score (ISS) for each patient. An ISS below 9 was classified as mild trauma, an ISS from 9 to 15 inclusive as moderate trauma, and an ISS above 15 was classified as severe trauma. The time courses of the plasma NGAL levels (mean ±standard error of the mean (SEM)) for patients with mild (n=52), moderate (n=26) and severe trauma (n=32) are shown in FIG. 1. The results show that the plasma level of NGAL on admission is directly related to injury severity and that this relation persists from the earliest time that a blood sample could be obtained to at least six hours thereafter. 

What is claimed is:
 1. A method of assessing severity of an injury in a subject that is due to physical or chemical causes arising from accidents, natural disasters or aggressive acts, wherein said injury is not due to natural disease and is not a kidney injury, said method comprising the steps of a. measuring a level of neutrophil gelatinase-associated lipocalin (NGAL) in a sample of bodily fluid from the subject within 12 hours after the injury has occurred, and b. determining the severity of the injury based on the measured level of NGAL, wherein the higher the level of NGAL the more severe the injury.
 2. The method of claim 1 wherein the bodily fluid is blood, plasma, serum or urine.
 3. The method of claim 1 wherein the bodily fluid is bronchoalveolar lavage fluid.
 4. The method of claim 1 wherein a functional activity of NGAL is measured in the sample.
 5. The method of claim 1 wherein the measurement of NGAL or a functional activity thereof is performed by means of one or more antibodies or other binding molecules capable of binding to NGAL or a ligand or product of its functional activity.
 6. The method of claim 1 wherein the measurement of NGAL or its functional activity gives rise to a quantitative or qualitative signal that can be read by visual inspection or by means of a portable reading device that can be carried to wherever an injured subject may be encountered.
 7. The method of claim 1 wherein NGAL or its functional activity is measured by an automated method.
 8. The method of claim 1 wherein the subject is a mammal.
 9. The method of claim 8 wherein the mammal is a human.
 10. The method of claim 1 wherein the injury is traumatic in origin.
 11. The method of claim 1 wherein the injury is due to exposure to a chemical agent.
 12. The method of claim 1 wherein the injury is due to exposure to radiation.
 13. The method of claim 1 for use in triage of victims of said accidents, disasters or acts.
 14. The method of claim 1, wherein the injury is any type of externally caused injury that is due to physical or chemical causes arising from accidents, natural disasters or aggressive acts, wherein said injury is not due to natural disease and is not a kidney injury. 